Developing a Suite of Resources to Improve Patient Adherence to Compression Stockings: Application of Behavior Change Theory

Figures & data

Figure 1 Overview of steps used in resource development using the BCW approach.

Figure 2 The impact-likelihood matrix for behavior prioritization.⁵³

Notes: Reprinted from Kneebone SL, Fielding K. The impact-likelihood matrix: a policy tool for behaviour prioritisation. Environ Sci Technol. 2017;70:9–20, Copyright (2017), with permission from Elsevier.⁵³

Table 1 Mapping of Barriers and Enablers to the Wearing of Compression Stockings, Linked to Michie’s COM-B Functions, Grouped by TDF Domains, and Rated on Their Justification for Inclusion

COM-B^Citation34 Component (Source of Behavior)	TDF^Citation39 Domain Link to COM-B	Target Behavior	Barrier - Considering Patients and Clinicians	COM-B Intervention Function		Patient Actioned Enabler: Behavior Change Technique/Description of Intervention Strategies	Clinician-Actioned Enabler: Behavior Change Technique/Description of Intervention Strategies	Impact-Likelihood/ Justification
CAPABILITY^Citation34
FUNCTIONS: Physical: Skills, abilities or proficiencies acquired through practice Psychological: Knowledge, memory, attention, decision processes, behavioral regulation						POTENTIAL ENABLERS: Physical: eg, workshops, skills-based training, assistive devices. Psychological: eg, distribution of educational material, educational meetings, mass media, Providing information or education
Physical Capability		Patient can put stockings on and take them off by themself	Unable without another person to assist	Environmental restructuring and enablement		Patient arranges outside assistance through own network of supports or clinician assists with this	Assisting patients to locate a suitable helper: family/friend/non-government agency to visit	A3: Hard but effective For inclusion in intervention
	Environmental context and resources		Unable without an applicator	Environmental restructuring, training, and enablement		Patient sources own applicator	Clinician provides an applicator and/or information regarding hire Clinician teaches patient how to use an applicator	A3: Hard but effective For inclusion in intervention
	Skills Social/ professional role		Lack of patient skills/ training Clinicians do not consider how patients don/doff stockings, and/or prioritize skills training	Training, education, enablement, and environmental restructuring			Clinician helps patients to develop the skills to don/doff stockings Clinician are given prompts and reminders to facilitate skills training Clinicians are given prompts to provide handouts to support patient education	A1: Easy and effective For inclusion in intervention
	Knowledge Skills	The patient can tolerate wearing stockings all day	Stockings are not comfortable as not positioned correctly by the patient due to lack of knowledge / clinician not prompting for this	Training, education, enablement, and environmental restructuring		Patient reads and retains information around correct stocking positioning and the need for regular adjustment	Clinicians are given prompts to inform patients around correct stocking positioning/need for regular adjustment with verbal education and provision of handouts	A1: Easy and effective For inclusion in intervention
	Knowledge Skills		Stockings are not comfortable as not the correct prescription/ill-fitting	Training, education, enablement, and environmental restructuring			Provide training/guidance for clinicians on how to choose the correct stocking Clinicians are given prompts to look for common problems with stocking comfort Provide prompts and tips for prescribing stockings so they are comfortable and well-fitting and problem-solving common problems	A1: Easy and effective For inclusion in intervention
Psychological Capability	Knowledge Social/ professional role	The patient understands that stockings should be worn all day	Lack of patient understanding of wearing regime Clinicians forget to provide the necessary information, or do not feel it is important	Enablement, environmental restructuring, and education		Patient hears, reads, and retains information around the timeframe for wearing stockings	Clinicians are given prompts via clinical templates, to remind patients at each appointment verbally and in writing Clinicians are given prompts to book OT Assistant phone calls for regular reminders	A1: Easy and effective For inclusion in intervention
	Knowledge Social/ professional role	The patient is caring for stockings correctly (to avoid them becoming worn out and no longer effective)	Lack of patient understanding of how to care for stockings Clinicians forget to provide the necessary information, or do not feel it is important	Education and enablement		Patient hears, reads, and retains information around how to care for stockings correctly	Clinicians are given prompts via documentation templates, to remind patients at each appointment verbally and in writing Clinicians are given prompts to book OT Assistants phone calls for reminders and support	A1: Easy and effective For inclusion in intervention
	Knowledge Social/ professional role	The patient has the knowledge of how to put stockings on and take them off	Lack of patient knowledge of how to put stockings on and off Clinicians forget to provide the necessary information, or do not feel it is important	Education, training, and enablement		Patient hears, reads, and retains information around how to put stockings on and off	Clinicians are given prompts to facilitate patient knowledge of how to put stockings on and off Clinicians are given prompts for relevant handouts to give to patients Clinicians are given prompts to book OT Assistant phone calls for support	A1: Easy and effective For inclusion in intervention
	Memory, attention, and decision process	The patient can remember instructions	Poor patient memory impacting ability to follow instructions	Environmental restructuring		Patient brings a carer to their appointment	OT calls each patient before an appointment to ask if they may need a carer to attend	A3: Hard but effective Not within scope of existing clinical processes to do this. Not for inclusion
	Memory, attention, and decision process Knowledge Social/ professional role	The patient appropriately reports issues to treating team of OTs	Lack of patient awareness of OT role extends beyond clinical appointment Clinicians forget to provide the contact details or reassurance to patients that they can call for help if needed	Education		Patient hears, reads, and retains information around phone number to call, and permission to seek help if needed	Clinicians are given prompts (including via clinical templates), to remind patients at each appointment verbally and phone number in writing	A1: Easy and effective For inclusion in intervention
MOTIVATION^Citation34
FUNCTIONS Reflective: Beliefs about capabilities and consequences, roles, identify, intentions, goals, optimism Automatic: Emotions, reinforcement such as rewards, incentives, punishment						POTENTIAL ENABLERS Reflective: eg, increasing confidence and challenging assumptions Automatic: eg, avoiding embarrassment
Reflective Motivation	Knowledge Skills Beliefs about capabilities	Clinicians have awareness of own skill level and gaps in knowledge and confidence to seek guidance to improve skills		Education, enablement, training and education			Clinicians are offered regular skills-based training and increased knowledge through Inservices and one-to-one training	A3: Hard but effective Existing clinicians do have regular training but outside scope to formally include this in the intervention Not included
	Knowledge Skills Beliefs about consequences	Patients feel validated, heard, and understood	Patients do not feel validated, heard, or understood leading to lack of motivation to follow instructions	Education and enablement			Clinicians are given prompts to consider the importance of their patient interactions Clinicians are given information with tips for how to improve this in practice	A1: Easy and effective For inclusion in intervention
Automatic Motivation	Beliefs about consequences	Patients can speak freely about issues that may be difficult or embarrassing	Lack of patient or clinician confidence to speak about difficult topics/patients wish to impress the clinician				Clinicians are given prompts to consider the importance of their patient interactions and to create a safe environment Clinicians are given information with tips for how to improve this in practice	A2: Easy but not effective Prompts will be given. For inclusion in the intervention
OPPORTUNITY^Citation34
FUNCTIONS Physical: Environmental context and resources Social: Social influences such as social pressure, norms, conformity, social comparisons						POTENTIAL ENABLERS Physical: eg, changes in physical structure, changes in scope of services, changes to the setting/site of service delivery, financial Social: eg, establishing social and cultural norms
Physical Opportunity	Environmental context and resources	Clinicians have sufficient time to deal with issues that arise during appointments	Lack of time in short clinical appointments meeting KPIs	Environmental restructuring			Clinics consistently offer longer appointments. Seek service change regarding allocation of budgets to allow for longer appointments	A3: Hard but effective In consideration of budget restraints this is considered difficult and is not included
	Environmental context and resources	Clinicians can offer urgent appointments at time of need	Lack of available appointments in high demand clinic	Environmental restructuring			Seek service change regarding more clinics to open with corresponding increase in staff hours	A3: Hard but effective In current economic climate, this is seen as not viable and is not included
Social Opportunity	Social Influences	Patients are comfortable to wear stockings in public and do so	Patients feel they look old, frail when wearing stockings. Lack of patient understanding of importance Clinician lack of awareness of this as a potential barrier	Training and education		Patient hears, reads, and retains information around normalization Patient accepts information provided	Clinicians are provided with the knowledge and skills to identify and address this with patients (normalization, options for colors/fabrics) -Clinicians are given prompts to consider this, and directions for how to approach this if identified	A1: Easy and effective For inclusion in intervention

Abbreviations: TDF, Theoretical Domains Framework; COM-B, Capability, Opportunity, Motivation, Behavior; OT, Occupational Therapy/Therapist.

Figure 3 The suite of resources.

Table 2 Barrier Identification Expanded for Detail, Linked with Its COM-B³⁴ Component, TDF³⁹ Domain and Source of the Enabling Behavior

Barrier Expanded	Question	COM-B Component	TDF Domain and Source of Enabling Behavior
Theme: Stocking comfort
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains of/ clinicians observe stockings are digging in at ankle	Are stockings digging in at the ankle?	Physical capability Psychological capability	Skills/social and professional role (clinician) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains stockings are too tight	Do stockings feel too tight generally?	Physical capability Psychological capability	Skills/social and professional role (clinician) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains of/ clinicians observe stocking slides down leg	Do stockings slide down the leg?	Physical capability Psychological capability	Skills/social and professional role (c) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains of/ clinicians observe stockings dig in at top of leg	Are stockings digging in at the top of the leg?	Physical capability Psychological capability	Skills/social and professional role (clinician) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains stockings too tight at base of toes	Are stockings too tight at the base of the toes?	Physical capability Psychological capability	Skills/social and professional role (c) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains stockings too tight over toes	Are stockings too tight over the toes themselves?	Physical capability Psychological capability	Skills/social and professional role (c) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains fabric irritates skin/clinician observes physical evidence of this	Is the fabric irritating the skin?	Physical capability Psychological capability	Skills/social and professional role (c) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Patient complains open toe stockings slide up foot with wear	Is the foot section sliding up the foot (open toe stockings)?	Physical capability Psychological capability	Skills/social and professional role (c) Knowledge, social/professional role (c)
Stockings are not comfortable as not the correct prescription/ill-fitting: Clinician notes large foot compared to thin leg not fitting into standard sizing	Is there a large foot compared to a thin leg?	Physical capability Psychological capability	Skills/social and professional role (c) Knowledge, social/professional role (c)
Patient complains stockings are too hot to wear at times	Do stockings feel too hot to wear sometimes?	Psychological capability Reflective motivation	Memory, attention, and decision process (p) Knowledge, social/professional role (c) Knowledge, skills, beliefs about consequences (p)
Stockings not tolerated as patient reacts to silicone top band: Patient complains fabric irritates skin/clinician observes physical evidence of this	Is there irritation from a silicone grip top/band?	Physical capability Psychological capability	Skills/social and professional role (c) Knowledge, social/professional role (c)
Theme: Patient understanding
Patient has limited understanding of their medical condition. Clinician observes patient is not able to describe why they have received a medical referral for stockings	Is there a limited understanding of their medical condition?	Physical capability Psychological capability	Knowledge skills (c) Memory, attention, and decision process (p) Skills/social and professional role (clinician)
Patient has limited understanding of the medical reason stockings are required. Clinician observes patient is not able to describe why they have received a medical referral for stockings	Is there a limited understanding of why stockings are needed?	Physical capability Psychological capability	Knowledge skills (c) Memory, attention, and decision process (p) Skills/social and professional role (c)
Patient describes a previous negative experience with stockings	Was there a previous negative experience with stockings	Psychological capability Reflective motivation	Memory, attention, and decision process (patient) Knowledge, skills, beliefs about consequences (p)
Patient describes conflicting medical advice	Was there previous conflicting medical advice?	Psychological capability	Memory, attention, and decision process (patient)
Patient describes low mood / clinician observes possible low mood	Could the patient be experiencing low mood?	Psychological capability Reflective motivation Automatic motivation	Memory, attention, and decision process (p) Knowledge, skills, beliefs about consequences (p) Beliefs about consequences (p)
Patient describes a low belief in their own abilities to manage wearing compression stockings	Does the patient have a low belief in their own abilities	Psychological capability Reflective motivation	Memory, attention, and decision process (p) Knowledge, skills, beliefs about consequences (p)
Theme: Concern about appearance
Patient describes a concern that stockings will make them look old/frail	Is the patient concerned that stockings would make them look old/frail?	Psychological capability	Memory, attention, and decision process (p)
Theme: Applying and removing stockings
Patient describes / clinician observes inability to put stockings on	Is the patient unable to put stockings on?	Physical capability Psychological capability	Knowledge, social/professional role Environmental context and resources (c and p) Knowledge, social/professional role (c)
Patient describes difficulty putting stockings on or taking them off due to existence of dressings that are disturbed in the process	Does the patient have wounds or dressings?	Physical capability Psychological capability	Knowledge, social/professional role Environmental context and resources Knowledge, social/professional role (c)
Patient describes / clinician observes inability to take stockings off	Is the patient unable to get stockings off?	Physical capability Psychological capability	Knowledge, social/professional role (c) Environmental context and resources (c and p) Knowledge, social/professional role (c)
Theme: Caring for stockings
Clinician observes that the patient does not know how to correctly care for their stockings	Does the patient not know how to take care of their stockings (knowledge)?	Psychological capability	Memory, attention, and decision process (p) Knowledge, social/professional role (c)
Clinician observes that the patient knows how to correctly care for their stockings but is not doing it correctly or consistently	Does the patient have difficulty taking care of their stockings (memory/planning)?	Psychological capability	Memory, attention, and decision process (p)
Clinician observes that patients have not contacted clinician to report a problem, instead waiting till their next scheduled review	Does the patient not know who to contact if they have any problems/ stockings need replacing?	Automatic motivation Psychological capability Reflective motivation	Beliefs about consequences (p) Memory, attention, and decision process (patient) Knowledge, social/professional role (c) Knowledge, skills, beliefs about consequences (p)

Abbreviations: TDF, Theoretical Domains Framework; COM-B, Capability, Opportunity, Motivation, Behavior; c, clinician; p, patient.

Figure 4 Three examples demonstrating links between barriers, intervention function and intervention prompted by the clinical decision tree.

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